CROI 2017 Abstract e-Book

Abstract eBook

Oral Abstracts

delivery of more patient-centred services and improvements in the quality of care. In the past, the introduction of POC technologies has put tremendous stresses in already fragile health care systems, amplifying by a hundred- to a thousand-fold issues of supply chain management, health care personnel shortage and quality assurance. The availability of data connectivity with these novel POC devices will allow countries to develop nationwide quality assurance and supply systems and streamline patient pathways. Lessons learnt from country uptake of other POC technologies and potential solutions have been incorporated in viral load introduction toolkits prepared by various implementing partners such as the US Centers for Disease Control and Prevention. These guidance tools need to be used with input from laboratory managers, health care providers and patient communities at every level of the health system. Leveraging innovations to take VL to scale is possible but will require closer collaboration of different stakeholders if countries were to achieve the third 90. 106 USING TECHNOLOGY TO IMPROVE ADHERENCE Richard T. Lester, Univ of British Columbia, Vancouver, Canada There already exists substantive evidence for how new and recent technologies can improve HIV treatment adherence. Yet, there remain major implementation gaps to overcome if achieving the third and final UNAIDS 90 (90% viral suppression by 2020) is to be met in a timely way at sufficient global scale. Some of the most pervasive and powerful technologies relate to the Digital Age and in particular the use of mobile phones as communication tools (mHealth) that can reach patients directly, or help their caregivers provide enhanced support. Evidence will be reviewed for what has worked, and what hasn’t (focusing on randomized controlled trials and systematic reviews) and an attempt to understand why. In network meta-analyses, only SMS and enhanced counseling support improved adherence and viral suppression outcomes, and multiple modalities used in combination may be superior to single modalities alone. WelTel, a two-way communication method between patients and caregivers on a text-messaging management software platform, will be used as an illustration but other innovations will be considered. Consideration will also be given as to what adherence technology modalities are likely to: 1) reach the highest proportion of those infected with HIV; 2) be acceptable among users; and 3) be feasible to scale in health systems (in time). Digital tools are not evenly distributed and different settings and key populations may require different strategies or offer new opportunities (e.g. smartphones and internet are reaching an increasing proportion of people in LMIC and more resourced settings, but remain will a minority within the 90-90-90 timeframe). Despite available data, there has been a failure to put evidence to action thus far - we will try to learn from those lessons. Issues such a local development and ownership of digital technologies may need to be rethought in favour of programs of ‘global ownership’ for scale. Data for cost-effectiveness and implementation science are starting to emerge but funding mechanisms have been elusive for the massive scale required. In order to harness technologies to improve treatment adherence and impact the third 90 in less than 4 years, serious investment needs to be made in the most cost-effective and far-reaching solutions that already exist without delay, and can be improved upon as technologies continue to evolve down the line. 107 REACHING KEY AND VULNERABLE POPULATIONS TO ACHIEVE THE THIRD 90 Ruanne V. Barnabas, Univ of Washington, Seattle, USA Substantial progress has been made on ART delivery, with 18 million HIV positive persons on ART (50% of people living with HIV). However, among key and vulnerable populations (men who have sex with men [MSM], sex workers, transgender people, people who inject drugs [PWID], adolescents, and children) the HIV care continuum requires strengthening, with a smaller (~5%-25%) proportion of HIV positive persons receiving ART. Reaching key populations for ART provision is critical to achieve viral suppression among 90% of persons on ART, for the clinical and transmission reduction benefits. Mathematical models estimating the impact of viral suppression among key and vulnerable populations on HIV incidence demonstrate the value of reaching key populations, particularly in concentrated epidemic settings. Effective strategies to reach key and vulnerable populations include actively involving key population members, using multicomponent interventions, and fostering open and effective client-provider communications. Simplified protocols for HIV care, including viral load testing, can strengthen services for key and vulnerable populations. 108 IF YOU CAN MAKE IT THERE: ENDING THE HIV EPIDEMIC IN NEW YORK Demetre C. Daskalakis, NYC DHMH, New York, NY, USA Science, community activism, and political will converge in the domestic epicenter of HIV/AIDS to generate a “Blueprint” to End the Epidemic (EtE) in New York City (NYC) and State. Through a process of evaluating strategies and identifying and leveraging resources, NYC continues to progress toward the achievable goal of decreasing the rate of new HIV infections to below epidemic levels. Increasing awareness of status, improving viral load suppression, magnifying the use of HIV medications for prevention, and supporting the health of often marginalized populations are the pillars of the NYC strategy to end HIV by making NYC “status neutral.” 109 HTLV-1: THE OTHER HUMAN RETROVIRUS Charles R. Bangham, Imperial College London, London, UK The human leukaemia virus HTLV-1 causes disabling chronic inflammatory diseases or an aggressive, rapidly fatal malignancy in about 10% of infected people. The risk of these diseases is strongly correlated with the proviral load, which frequently exceeds 10% of peripheral blood mononuclear cells. The virus, which is non-cytolytic, drives proliferation of the infected CD4+ T cell, and the high proviral load is limited by a strong, chronically activated cytotoxic T lymphocyte (CTL) response to HTLV-1. HTLV-1 does not release cell-free virions, but propagates both within and between hosts by cell-to-cell contact, via the virological synapse. In addition to the virological synapse, the study of HTLV-1 has made many contributions to human retrovirology, including the discovery of the IL-2 receptor CD25, IL-15, selective infection of virus-specific cells, T-cell fratricide, and the dynamics and determinants of CTL quality. Until recently, it was believed that HTLV-1 was latent in vivo, and persisted chiefly by continuous oligoclonal proliferation of about 100 clones of HTLV-1-infected CD4+ T cells. However, we have shown that a typical individual carries between 10^4 and 10^5 clones, and the proviral load – the chief correlate of disease – is determined by the number of clones, not by oligoclonal proliferation. We recently made the surprising discovery that HTLV-1 alters host chromatin structure in the infected cell, by binding the chromatin architectural protein CTCF - the chief protein that regulates higher-order chromatin structure and gene expression in vertebrates. We are now testing two hypotheses that arise from this observation. First, that CTCF binding regulates HTLV-1 latency by controlling selective plus- and minus- strand transcription of the provirus, and so determines the observed single-cell heterogeneity in proviral expression, both within and between clones. Second, that the abnormal chromatin looping caused by CTCF can deregulate host gene expression and so may act as an oncogenic driver. 110 A COMBINATION INTERVENTION STRATEGY FOR HIV LINKAGE AND RETENTION IN MOZAMBIQUE Batya Elul 1 , Matthew R. Lamb 1 , Maria Lahuerta 1 , Fatima Abacassamo 2 , Laurence Ahoua 3 , Stephanie Kujawski 1 , Maria Tomo 2 , Ilesh Jani 4 1 Columbia Univ, New York, NY, USA, 2 Cntr for Collab in Hlth, Maputo City, Mozambique, 3 ICAP at Columbia Univ, Maputo City, Mozambique, 4 Inst Nacional de Saude, Maputo, Mozambique Background: Identifying scalable interventions to strengthen linkage to and retention in HIV care is essential to ensuring individual and population benefits of ART. Methods: Engage4Health, a cluster-randomized controlled trial implemented at 10 health facilities in Mozambique, evaluated the effectiveness of a combination intervention strategy (CIS) vs the standard of care (SOC) on the combined outcome of linkage to care within 1 month and retention in care at 12 months following HIV diagnosis. CIS included: (1) point-of-care CD4+ count at HIV testing sites; (2) accelerated ART initiation for eligible patients; and (3) SMS appointment reminders. A subset of CIS participants additionally received non-cash financial incentives (CIS+FI). Adults >18 years newly diagnosed with HIV and willing to receive HIV care at the diagnosing health facility were enrolled from 4/13-6/15 and followed for 12 months. Main analyses assessed outcomes at the diagnosing facility using medical record abstraction, while sensitivity analyses examined outcomes at any health facility using self-reports collected during follow-up interviews. Log-Poisson models were used to estimate the relative risk (RR) of outcomes in intent-to-treat analyses, with additional models adjusting for clustering within sites and patient characteristics using propensity score matching.

Oral Abstracts

41

CROI 2017